Endoscopy and Endosurgery

This module will cover the history of endoscopy and the development of instrumentation to current day including current applications of endoscopy and minimally invasive surgery in human and veterinary surgery. The structure, function and care of the rigid and flexible endoscope will be covered in detail together with advice on suitable instrumentation for different situations in general practice. Accessory instrumentation will also be discussed in detail and available for use in a dry lab environment. Special attention will be given to the use of electrosurgery and electrosurgical equipment in Minimally Invasive Surgery (MIS) as this is an important means of haemostasis and requires special care in this field. Finally advice on incorporating endoscopy into general practice will enable you to realise a realistic return on your investment.

Key Learning Objectives:

• Describe the history and current applications of endoscopy in human surgery and relate this to current veterinary practice
• Describe and identify endoscopic instrumentation including rigid and flexible endoscopes, and compare the advantages and disadvantages of each.
• Select instruments that are best suited to their individual practice and patients.
• Discuss the application of accessory instrumentation for rigid and flexible endoscopes
• Explain how electrosurgery is used in minimally invasive surgery and how this differs from open surgical techniques
• Demonstrate how to clean and care for endoscopic equipment
• Discuss the incorporation of endoscopy into a veterinary practice

By using a mixture of didactic, video-based and hands-on practical teaching, this module will cover the techniques of using flexible end, with practice in models. It will cover patient preparation and endoscopic techniques. The module will enhance your abilities to recognise abnormalities and obtain diagnostic samples. Therapeutic uses of endoscopy, including removal of foreign bodies and placement of feeding tubes will also be demonstrated. Key learning objectives:

• List the indications for respiratory tract endoscopy
• Describe the possible complications of respiratory tract endoscopy and how to deal with them.
• Describe patient preparation and general endoscopic technique for examination of upper and lower respiratory tracts
• Distinguish endoscopic appearance of nasal cavity, larynx, trachea and bronchi in health and disease
• Describe sample collection techniques, which to use and when.
• Describe foreign body retrieval and feeding tube placement techniques
• Demonstrate the above techniques effectively using anatomical models

By using a mixture of didactic, video-based and hands-on practical teaching, this course will cover the techniques for diagnostic upper gastrointestinal flexible endoscopy, using anatomical models, and will cover patient preparation and endoscopic techniques. The module will enhance your abilities to intubate the duodenum and to recognise abnormalities in the upper GI tract and to obtain diagnostic samples.  Key learning objectives:

• Discuss when upper gastrointestinal endoscopy is indicated and when other techniques may be preferable. Describe what diagnostic procedures should be performed before Upper GI endoscopy.
• List the possible complications of upper gastrointestinal endoscopy
• Describe patient preparation for optimal examination technique for the upper gastrointestinal tract and general technique to enable a thorough examination including intubation of the pylorus.
• Distinguish endoscopic appearance of oesophagus, stomach and duodenum in health and disease
• Describe biopsy techniques in order to obtain optimal biopsies for histology and/or cytology/culture
• Demonstrate manipulation of the endoscope effectively 

By using a mixture of didactic, video-based and hands-on practical teaching, this module will cover the techniques of using and caring for flexible endoscopes based on an understanding of their construction and capabilities. Instruction in diagnostic lower gastrointestinal flexible endoscopy will cover patient preparation and endoscopic techniques using a model. The module will enhance your abilities to recognise abnormalities and obtain diagnostic samples.  Key learning objectives:

• Discuss how to choose a suitable endoscope for GI endoscopy
• Demonstrate how to use a flexible endoscope
• Describe how to obtain samples from the GI tract
• Compare when lower gastrointestinal endoscopy is indicated and when other techniques may be preferable
• Describe the possible complications of lower gastrointestinal endoscopy
• Describe patient preparation for optimal examination of the lower gastrointestinal tract and general endoscopic technique to enable a thorough examination.
• Identify the endoscopic appearance of ileum, colon, caecum and rectum in health and disease
• Describe methods and instrumentation to maximise the potential for gastric and oesophageal foreign body retrieval.
• Identify the indications for feeding tube placement and describe optimal techniques and instrumentation for endoscopic placement.

The basic technique for efficient rhinoscopic examination of the nasopharynx, nose and para-nasal sinuses will be discussed in detail along with biopsy techniques and common nasal pathology including neoplasia. Laser debulking of nasal masses will be discussed and diagnosis and treatment of nasal aspergillosis using a minimally invasive technique will also be covered. Endoscopic examination of pharyngeal stick injuries and other traumatic wounds and fistulas will also be discussed. There will be ample opportunity to practise these techniques in a wet-lab environment.

Key learning objectives:

• Identify the anatomy of the nasal meati and describe how to explore them endoscopically
• List the range of rigid endoscopic equipment available for examination of the upper respiratory tract and choose which is best suited to your patient
• List the indications for rigid rhinoscopy and any additional imaging techniques required.
• Describe patient preparation for rigid rhinoscopy
• Demonstrate general endoscopic techniques for examination of the upper respiratory tract using a rigid endoscope.
• Describe the advantages and disadvantages of rigid vs flexible endoscopy in different areas of the upper respiratory tract.
• Outline the importance of correct biopsy technique to get diagnostic samples
• Demonstrate how to examine the frontal sinuses
• Compare normal nasal appearance and common nasal pathology
• Describe how to recognise, diagnose and treat nasal aspergillosis
• Describe how to recognise, diagnose and treat nasopharyngeal stenosis
• Describe how to recognise, diagnose and treat nasal tumours including laser ablation for palliation.
• Discuss other ‘oscopies’ including exploration of stick injuries and fistulae
• Demonstrate the above techniques effectively in a wet-lab environment

The module will cover basic video-otoscopy techniques including the examination of the external ear canal and tympanic bulla. The technique of myringotomy will be discussed in detail together with collection of diagnostic samples from the ear. Examination of the lower urinary tract of the bitch and queen will be covered in detail including instrumentation and technique. Diagnosis and treatment of common pathology including paramesonephric remnants, ectopic ureters, urinary sphincter mechanism incontinence and transitional cell carcinoma will also be covered and there will be ample opportunity to practise these techniques in a wet lab environment.

Key learning objectives:

• Identify the anatomy of the ear and in particular the sensitive structures of the middle ear.
• List the indications for otoendoscopy, and the advantages over traditional otoscopy
• Demonstrate proficiency at myringotomy and examination of the middle ear.
• Describe possible complications of otoendoscopy and outline post-operative treatment.
• List the indications for urethrocystoscopy and vaginoscopy in the dog and cat
• Describe patient preparation
• Demonstrate proficiency in general endoscopic techniques for urogenital tract examination in the dog and cat
• Describe the normal endoscopic appearance of the vagina, urethra and bladder
• Compare the appearance of the urogenital tract in health and disease
• Describe options for minimally invasive treatment of conditions such as ectopic ureters, paramesonephric remnants, urethral sphincter mechanism incompetence, strictures and transitional cell carcinoma.
• Explain when to use the laparoscopic cystoscopy approach where transurethral access is not possible or adequate (i.e. for large stones, or in the dog or tom cat)
• Describe biopsy and sampling techniques and demonstrate these effectively in a wet lab environment

The module will cover the basic approach and principles of laparoscopy in the dog and cat. Basic laparoscopic procedures will be covered and several laparoscopic procedures will be covered in detail including liver, pancreas and other organ biopsy techniques, full thickness bowel biopsy, laparoscopic gastropexy and GI foreign body removal, jejunostomy tube placement and cryptorchidectomy. Laparoscopic assisted cystoscopy will also be covered and there will be ample opportunity to practise laparoscopic techniques and instrument handling in a dry and wet-lab environment.

Key learning objectives:

• List the indications for laparoscopy and describe the advantages and disadvantages of a minimally invasive technique vs open laparotomy.
• Describe patient preparation for laparoscopy.
• Explain the anaesthetic implications of abdominal insufflation and describe optimal insufflation techniques.
• Demonstrate Veress needle placement and insufflation in a wet lab environment
• Explain the principles of port placement for ergonomic instrument use and optimal tissue handling.
• Compare the normal endoscopic appearance of the abdominal cavity and its organs in health and disease.
• Demonstrate abdominal organ biopsy techniques in a wet lab environment.
• Describe laparoscopic surgical techniques for gastropexy, gastric or intestinal foreign body removal, cryptorchid castration and laparoscopic assisted cystoscopy.
• List the possible complications of laparoscopy

Minimally invasive surgery has transformed the way surgical procedures have been performed over the past twenty years and many veterinary clinics are now performing many or all of their bitch spays laparoscopically. The benefits are self-evident and the procedure is well received, indeed sought out, by clients. Many clinics already own flexible endoscopy equipment and thus have much of the basic equipment necessary for rigid endoscopy and laparoscopy. Additional equipment and training is required to perform laparoscopy and this expense must be justified.

Most surgeons starting laparoscopy would consider the bitch spay as the core procedure and main reason for investing in the equipment. It is a routine procedure that is done on an almost daily basis and will therefore provide a return on investment as well as providing sufficient practise in technique to enable surgeons to do other, more advanced techniques and expand their repertoire. 

Key learning objectives:

• Review the principles of haemostasis for laparoscopic surgery including electrosurgery, vessel sealing devices, clips and sutures
• Compare the advantages of ovariectomy vs ovariohysterectomy and define when it is necessary to remove the uterus.
• Compare the techniques for laparoscopic ovariectomy and ovariohysterectomy and demonstrate them in a wet lab environment.
• Compare the advantages and disadvantages of a single port, two port or three port technique for laparoscopic ovariectomy and describe the instrumentation required.
• List the possible complications of laparoscopic surgery.
• Discuss the financial viability of incorporating laparoscopic spays into private practice

Key learning objectives:

• Describe the instrumentation necessary for arthroscopic procedures
• Describe common joint pathology in the elbow, stifle and shoulder joints and distinguish the endoscopic appearance of these joints in health and disease.
• List the indications for arthroscopy
• Describe patient preparation and the positioning and creation of portals for elbow, shoulder and stifle arthroscopy
• Demonstrate the above techniques in a wet-lab environment

Key learning objectives:

• Demonstrate proficiency at arthroscopic examination of the elbow, shoulder and stifle joints in cadavers in a wet lab environment
• Demonstrate simple arthroscopic surgery of the elbow and shoulder
• Describe the possible complications of the above procedures
• Practise the above techniques in a wet-lab environment

Exploratory thoracotomy is rarely performed in practice due to patient morbidity and mortality. However, thoracoscopy provides better surgical exposure, a magnified well illuminated image and greatly decreased morbidity and mortality making exploratory thoracoscopy a useful diagnostic and therapeutic tool for the general practitioner. The indications for thoracoscopy will be discussed and the basic principles and approach to the thoracoscopic examination of the chest will be covered. The benefits of the paraxiphoid transdiaphragmatic approach and the intercostal approach will be compared in relation to some common surgical procedures. Biopsy techniques and pericardectomy will be covered in some detail and other thoracoscopic procedures will be reviewed. Instrument handling techniques will be practised in a dry lab environment before practicing actual procedures in a wet lab. Key learning objectives:

• Review the instrumentation necessary for thoracoscopy procedures
• Describe the indications for diagnostic or therapeutic thoracoscopy
• Describe patient preparation and discuss anaesthetic techniques for thoracoscopic surgery.
• Identify the approaches to the thoracic cavity, including positioning of telescope portals
• Describe the techniques for an exploratory thoracoscopy, lung and lymph node biopsies and pericardectomy and demonstrate these in a wet lab environment
• Describe the use of minimally invasive techniques for more advanced thoracic surgery such as lung lobectomy, mediastinal masses, PRAA, PDA and pyothorax
• List the possible complications of thoracoscopy
• Practise some of the above techniques in a wet-lab environment

Lasers are becoming more common in first opinion veterinary practice and diode lasers in particular lend themselves extremely well to minimally invasive procedures as the laser light is delivered via a flexible fibre that can be passed down the instrument channel of the endoscope. This enables the surgeon to resect tissue, de-bulk tumours and provide haemostasis with extreme precision.

The module will include discussion of the types of laser equipment available as well as the techniques and application of lasers in endoscopy including the treatment of GI, nasal and bladder tumours and for the resection of ectopic ureters. There will be several lasers available for practise of these techniques in the wet lab. Key Learning Objectives:

• Summarize a basic understanding of laser physics and principles of use including tissue interactions, contact and non-contact mode, continuous and pulsed
• Review the equipment available for laser surgery in animals.
• Discuss the use of lasers in conjunction with endoscopy
• Describe how to perform laser debulking of tumours in the GI tract, nose and bladder as well as resection of ectopic ureters
• Describe the possible complications of laser surgery
• Demonstrate some of the above techniques in a wet-lab environment